The science journal Nature ran an editorial on 8 October under the title, “Let patients help define long-lasting COVID symptoms”. In my short response to this editorial, I argue that public policy which considers only COVID mortality and COVID-morbidity (i.e., “long-COVID”) will be ill-founded and in danger of losing public support. There is a third element in any equation which seeks to capture the total burden of disease, an element I suggest might be called “Collateral COVID”.  Giving a label such as “Collateral COVID” to the wide-ranging and multiplying indirect effects of COVID policies would help ensure that such effects are given due recognition (through measurement) and weight (through ethical deliberation) in public policy decisions.

Recognising the on-going, non-fatal, medical symptoms of SARS-CoV-2 infection is important (Nature 586: 170; 2020).  Adopting a nomenclature, such as “long-COVID”, for designating these symptoms of morbidity is a way of ensuring they become part of public discourse, strategy design and policy formation.

But the same should be said for all the indirect effects of this coronavirus pandemic induced by the adoption of specific policies for managing COVID-19 risk.  Such effects too should be given formal and clear recognition through bespoke labelling.

These indirect effects include rises in deaths from undiagnosed or untreated cancers, unmanaged heart disease, increases in suicides and still-births, child deaths caused by suspension of vaccination programmes, deterioration of mental health, increases in domestic violence, and so on.  For example, we learn today of the 26,000 excess deaths occurring in domestic homes, most of which are not COVID related but which result from suspension or contraction of hospital services because of COVID policy, or else because people have been too afraid to attend hospital.

And then there are other social pathologies induced by COVID policies, such as the long-term consequences of impaired child learning, de-socialisation and loneliness, unemployment, and the erosion of civil liberties. 

These indirect effects of SARS-CoV-2 – induced by pursuing certain public health policies rather than others – must also be made visible through labelling.  Perhaps we should call these aggregate effects “collateral-COVID”. 

Yes, we should be counting direct mortality caused by COVID-19 and, yes, we should be identifying and measuring additional morbidity caused by “long-COVID”.  But a defensible public policy for managing the pandemic must consider the total public burden of disease, both direct and indirect (“collateral COVID”) effects. 

Any ethical policy strategy for dealing with COVID-19 should seek to minimise the weighted sum of these three elements: COVID mortality, “long-COVID” and “collateral COVID”.  And it must also be explicit about the relative weighting assigned to these different harms when determining the total burden of disease resulting from any COVID-19 strategy. This weighting is a political and ethical choice, about which reasonable people can — and should — disagree. It is not the result of any scientific calculation or model.

Mike Hulme, 19 October 2020